Wednesday, Dec 12 2012
• 11 a.m. (ET)

Mind And Body: Head Injuries And What New Research Means For Football

A new study released last week looks at the brains of people who experienced repeated head injuries. It provides some of the clearest evidence yet linking recurring mild head trauma to long-term brain disease. Of the 85 people in the study, 50 had been football players. Athletes who play contact sports are always vulnerable to head injuries, but these days, football is in the spotlight. From youth leagues to the NFL, questions are being raised about the prevalence of head injuries and what can be done to make the game safer. For our series “Mind and Body”, Diane and her guests discuss the latest science on head injuries and how to best protect players.

Guests

Mary Ann Easterling
wife of former NFL safety, Ray Easterling.

Mark Meana
chairman of the Fairfax County Youth Football League.

Dr. Robert Cantu
co-director of the Center for the Study of Traumatic Encephalopathy and co-founder of the Sports Legacy Institute.

Dr. Gerard Gioia
director of the Pediatric Neuropsychology Program at Children's National Medical Center and director of the Safe Concussion Outcome, Recovery & Education (SCORE) Program.

Stefan Fatsis
panelist on Slate.com’s sports podcast “Hang Up and Listen", regular Friday sports commentator on NPR's "All Things Considered", and author of "A Few Seconds of Panic: A Sportswriter Plays in the NFL"

Are concussions linked to bipolar disease? Who is more likely to suffer the football injury, the tackler or the player getting tackled? Dr. Gerard Gioia, director of the Pediatric Neuropsychology Program at Children’s National Medical Center, answered these listener questions and more. Some questions have been edited for space and clarity.

Q:When should a young adult stop playing soccer due to repeated concussions? My son started soccer at age 5, didn’t start doing headers of the ball until Middle Scool, had a lacrosse concussion as a freshman in high school with symptoms lasting less than a day and a second concussion one week later in soccer also with symptoms lasting less than a day. He didn’t restart soccer for a week and his Impact baseline testing was at baseline. He had no further injuries for 5 years when he had another soccer concussion and it took 2 weeks for his impact testing to return to baseline. His symptoms were less than a day. When should it be recommended that he stop soccer? — from Ann via email

A: We have general criteria for stopping participation in a contact sport with repeated concussions — multiple concussions, with subsequent concussions that are produced by less force to the head/body, that take longer to recover from, or that produce lasting cognitive, emotional, or physical symptoms. This patterns concerns us that the brain may becoming more vulnerable to forces, and would indicate the need to stop contact sports. This determination should be made by a concussion specialist after a careful clinical exam, neurological exam, neuropsychological testing and thorough symptom assessment.

Q:How come, when we know so much about sustaining hits regularly, players continue to congratulate each other by butting helmets, or hand-clipping a helmet of another player? — from susanhepler2602 via Web

A: Not every force to the head has dire consequences. Although the view that the number of subconcussive blows is seen theoretically as related to CTE, the brain does have tolerances for forces that do not produce any kind of known effects. A single head butt or slap to the head is not likely to have any adverse effects.

Q:Today’s show deals with brain trauma and CTE. Some symptoms were given for CTE, but they seemed to me to be quite vague. Can you please offer some detail about how CTE is diagnosed in order to avoid ambiguity with other conditions which may have similar appearance? — from Jeff via email

A: At this point, CTE cannot be diagnosed while the person is still alive. It is only confirmed after death when a careful and specialized exmination of the brain tissue is conducted. Dr. Bob Stern at Boston University is working on research now that is attempting to develop diagnostic criteria and tests that would allow diagnosis in the living person. The symptoms and presentation of CTE is similar to the presentation of other psychiatric and neurological disorders, though the BU researchers indicate that the cause / problem in the brain is unique to CTE.

Q:I had a traumatic injury to my head as a toddler (fell between the handrail and stairs and landed on my head on the basement floor below) and am now in my early 30s. Are there specific things I should be aware of as I get older? — from Jason via Facebook

A: It is important to note that virtually all people recover from an uncomplicated concussion fully without any long-term effects. Following your injury, if you did not have any time-related problems with your development or learning or social-emotional functioning (i.e., within a few days to a week post-injury), then there is no reason to be concerned that the injury as a toddler had any effect on you as an adult.

Q:My husband and I would like our boys to participate in team sports, but fear of head injuries like football. My oldest is 7 and youngest is 5, so we have some time to do some research. What would you recommend? I was thinking of swimming and golf, my husband was thinking of wrestling. Do we worry too much? — from Helen via Facebook

A: As a parent, with all the current media about concussions and youth sports, it is hard not to be worried. As I had said on the program, in whatever sport you choose, you need to do your homework with the league and ask questions like:

Does the league have a general policy in how they manage concussions?

Do you coaches take a concussion education and training course? Who is responsible for the sideline concussion recognition and response to suspected concussions?

Do the coaches have readily available during practice and games the Signs & Symptoms cards, clipboards, fact sheets, smartphone apps, etc. to guide them in their proper recognition and response of a suspected concussion?

Are the parents given any education, and what is the policy for informing parents of suspected concussions?

When do you allow a player to return to play the sports? (Correct answer – when an appropriate medical professional provides me with written clearance that the athlete is fully recovered and ready to return.)

Do you / does the league teach the sport’s technique in a way that is “headsafe” by not putting the head in a direct position to be struck? If the player does demonstrate unsafe technique during practice or a game, do you re-instruct them with the proper technique/ method?

If a contact sport, how often (# days a week, # minutes per practice) do you practice with live contact? Is that any different than past years?

Do you encourage parents to attend practice? How amenable is the league/ team / you (coach) in getting feedback from a parent if they are concerned about their child’s safety as it relates to their learning of the game?

As for which sports to choose, you have to be comfortable with contact sports if your son is going to play. There is a risk benefit equation – and you need to feel comfortable – based on the information you gather from the questions above – that safety is a priorty.

Q:A CT scan is not without risks but they are recommended routinely by insurance nurse lines following any bump to the head. What outcomes from the use of CT in diagnosing and treating a child make the risk worthwhile? — from Cyle via Facebook

A: CT sans because of the radiation exposure to the child’s brain should be used judiciously. They should not be done standardly or routinely. Generally speaking, most kids with a concussion do not need a CT scan. There are now decision rules for when to have a CT scan done, but this is typically done only when there is significant concern that the child may have sustained a significant brain injury or may be deteriorating in their function (see www.cdc.gov/concussion and search for Concussion Danger Signs). A very large study by the Pediatric Emergency Care Applied Research Network (PECARN) has published the decision rules that should be applied to reduce harmful exposure to undue radiation from CT scans.

A: Cheerleading is a sport that has clear risks for concussion in both the flier and base positions, with increasing recognition by the governing body of the need to reduce the risk. We see many cheerleaders in our clinic – and there continues to be a need for improvements in concussion education amongst the coaches and participants. But positive strides are being made.

Q:Are there cross studies with brain injuries suffered by troops in combat? — from @ronehardin

A: The military has had a signficant focus on brain injuries in their troops with a serious investment of clinical and research dollars (more than 2.5 billion dollars) over the past 5-6 years toward better diagnosis and treatment.

Q:Who is more likely to suffer the injury, the tackler or the player getting tackled? — from @billradun

A: For more serious sports neurological injuries (permanent brain injury and spinal cord injuries), the National Center for Catastrophic Sport Injuries at UNC tells us that the tackler represents about 2/3 of the injuries. These injuries, by the way, were found mostly in high school athletes (82-90 percent) not youth players (2.5 percent).

Q:I wonder if they have extended their studies to victims of child abuse? I know many children that have been hit on the head many times and I wonder if they have studied children and adults that were victims of child abuse. — from jturne02 via Web

A: Not as of yet, although this is an interesting question that should be studied.

Q:Are concussions linked to bipolar disease? My wonderful nephew played football in high school and college and suffered several concussions. One sent him unconscious to the hospital. He has had several severe bipolar episodes, the first when he was in college and the last a year ago when he was in his mid-40s. — from dimaurie via Web

A: Though this has not been studied specifically, concussions alone do not likely directly produce bipolar disease in most people, although in the short-term concussion does produce difficulties managing or controlling one’s emotional responses. It is important to note that most concussions do not produce long-term problems as far as we can tell, but in some people a significant concussion history may be one factor amongst others that worsens emotional functioning.

A: There is a lot of work that is being done to improve helmets but their main purpose is to protect the skull from fracturing. The helmet, and its padding, cannot absorb enough of the force to keep the brain from moving back and forth inside the skull. It is the stretching, straining, and compression of the brain’s soft tissue that results in the concussion.

Q:I have followed this problem of head injuries from football for many years. It was the primary reason I got my son interested in soccer to avoid his being involved in football. As the athletes get bigger, faster and stronger, the movement in the field seems to be to provide helmets, shoulder pads, knee pads, elbow pads that are harder and harder. Thus, when a huge defensive player running as fast as he can delivers a helmet to helmet blow to a ball carrier, the transfer of energy travels right to the brains of the two players. Why don’t those in charge insist on equipment that has shock absorbent padding on the outside, especially on football helmets, so that the energy at contact is dissipated or redirected before it affects the brain? — from Cliff via email

A: To date, the efforts to develop helmets to dissipate or redirect forces that produce concussion has not been successful though a number of companies have attempted to do so. At this point, the helmet, and its padding, cannot absorb enough of the force to keep the brain from moving back and forth inside the skull. It is the stretching, straining, and compression of the brain’s soft tissue that results in the concussion.

Q:I had multiple concussions as a child, three of which resulted in me being knocked unconscious. All of these incidents occurred before I reached 16. I am now 36 years old and I’m notorious for forgetting things. Is there the potential that there is a link between the two? If so, would you recommend that I see a specialist or are there any effective treatment options? — from Sonny via email

A: While it is difficult to know what the contribution of the multiple concussions may have been on your current functioning, there is a certainly an increased risk of long-term problems with a history of multiple injuries. I would recommend an evaluation by a concussion specialist who might be able to unravel your history and determine the likely relationship and make recommendations for treatment.

Q:I see that recently a lot of focus is on football players. My question is what about the sport of boxing. Are you finding a lot of head injuries in boxers? – from Dae via email

A: Boxing has long been studied, and concussions are frequent, and in fact the objective of boxing.

Q:I am studying neurobiology at the University of Cincinnati and am greatly enjoying your discussion of CTE. I have a question about the study however. It was stated on your show that some of the symptoms include behavioral disturbances, but was it looked into if these patients had these behavioral characteristics prior to the injuries? Or if these characteristics are common among the athlete’s peers? I’m just thinking that some of the symptoms described (aggression, trouble handling frustration, etc) could be the reason these people found football as an outlet or could have been bred in all of their training to perform. — from Dylan via email

A: This is a great question and one your should direct to the study’s primary authors, Drs. McKee, Cantu and Stern.

Q:Could you comment on concussions in other sports such as during a collision at the plate with a catcher in baseball? — from Lee via email

A: All sports have some risk of concussion if there is any potential for head contact forces – catchers in baseball are the highest risk in baseball largely due to foul tips hitting them in the mask unexpectedly and possibly frequently in some cases. Soccer, lacrosse, ice hockey, wrestling, ruby, field hockey, basketball all have risks. The equestrian sports have the highest risk.

Transcript

11:06:56

MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Today for our ongoing series "Mind and Body," we'll look at new research showing a clearer link between repeated head trauma and long term brain disease. There are now questions about the safety of contact sports like football.

11:07:17

MS. DIANE REHMHere to discuss the science and the reaction from the sports community, Dr. Gerard Gioia of Children's National Medical Center here in Washington D.C. Mark Meana of the Fairfax County Youth Football League in northern Virginia, Stefan Fatsis, sports journalist and joining us from his office in Concord, Mass. Dr. Robert Cantu. He's a neurosurgeon and author of the book titled, "Concussions and Our Kids."

11:07:52

MS. DIANE REHMThroughout the hour, I'll look forward to hearing from you. Join us on 800-433-8850, send us an email to drshow@wamu.org, feel free to follow us on Facebook or Twitter. Good morning to all of you.

11:08:12

MR. MARK MEANAGood morning.

11:08:12

MR. STEFAN FATSISGood morning.

11:08:13

DR. GERARD GIOIAGood morning.

11:08:13

DR. ROBERT CANTUGlad to be here.

11:08:14

REHMDr. Cantu, I'll start with you. You're the co-author of the new study, describe your findings. Dr. Cantu, are you there? Let's see if we have him. Dr. Cantu? No, he's not there. All right, I'm going to go to you, Dr. Gioia. Tell us about CTE and symptoms?

11:08:46

GIOIAWell, chronic traumatic encephalopathy is something obviously that Dr. Cantu and his group, Dr. Stern, Dr. McKee have been studying closely for the last several years. It is not my area of specialty, quite honestly with children, but certainly in their work they are finding that there seem to be some indications in a variety of athletes where there are deposits in the brain of certain proteins, some abnormal amounts.

11:09:20

GIOIAAnd with that seem to be associated with a number of cognitive, behavioral, emotional kinds of changes in those individuals that have been found to have that and some pretty devastating kinds of life circumstances, particularly in midlife to older adults.

11:09:41

REHMAll right, and I think now Dr. Cantu is back with us. Good morning, sir.

11:09:47

CANTUGood morning, Diane. I was never not with you, but you weren't with me, I guess.

11:09:52

REHMOkay. Well, there we are. Tell us about the findings of your new study?

11:10:00

CANTUWell, Dr. Ann McKee's the leader author on this study and what it really is, is the largest series of cases of chronic traumatic encephalopathy in the world's literature. It more than doubles the cases, these are 68 new cases out of the 85 individuals that were studied and the sheer volume of it is very impressive but the other parts of the study that I think are very useful is a grading system for CTE in terms of severity and it also, I think at least in my mind, is very worrisome in the sense that six of the cases, six of the 68, were in high school. So this disease can be seen as early as one in their teens.

11:10:54

REHMAnd tell me how many of those, not just the ones in high school, but the 68 men, how many of those happened to be football players?

11:11:13

CANTUThirty-three played in the National Football League of them and approximately another 15 were in college and then the six in high school.

11:11:26

REHMSo tell me how the symptoms present themselves and how people are diagnosed with CTE?

11:11:40

CANTUThe symptoms are primarily are cognitive symptoms, difficulties early on with attention and focus and also insight in judgment issues and also emotional issues, the hallmark of them being difficulty with handling frustrating circumstances so that both physical and verbal abusive behavior is very common with these individuals. Other symptoms that are very common in the emotional category are depression, anxiety and sometimes paranoid behavior.

11:12:18

REHMStefan Fatsis, you've been following sports of all kinds for a long time but you just heard Dr. Cantu say that about 50 of the people in his study had played football and about 30 had played professional football. How prevalent do you believe this to be in football generally?

11:12:50

FATSISI think it's unpredictable and that's part of the issue here. The science is going to catch up to the behavior. We have tens of thousands people play football, millions play if you include youth players. At the NFL level these are athletes that have been sustaining hits regularly in the sport for 10, 20 years on average, most for upwards of 20 years. Most athletes in the NFL started playing football when they were very young.

11:13:20

FATSISThere is a tremendous concern in the NFL among players, there's a much greater awareness thanks to the kinds of work that Dr. Cantu has done, thanks to reporters like Allen Schwartz of "The New York Times," who over the last three or four years really brought this issue into light and the gaining publicity, the growing publicity that this issue has gotten.

11:13:41

FATSISHas that tempered behavior among players? No, and I think that's one of the critical issues here to think about. NFL players are grown adults, they understand what they're getting into, they are highly aware of the dangers that they put their bodies at risk of during their careers.

11:13:58

REHMActually, some have been given bonuses to make harder hits.

11:14:06

FATSISThe, well there's some, there was a report issued yesterday by the former commissioner of the NFL, Paul Tagliabue, who exonerated some of the players in this case, involving the New Orleans Saints. But yes, there is a cultural violence and we have to appreciate that the NFL is a culture of violence.

11:14:22

FATSISPlayers understand that, but they also are growingly concerned about what it's doing to their bodies. Is that going to stop them from playing? No. I spent a summer with the Denver Broncos to write a book about life in the NFL. I was on the team as a place kicker, I never got hit because I would've died if they had hit me because I'm not...

11:14:41

REHMThey're bigger than you are.

11:14:43

FATSISThey're substantially bigger than I am. But I talked to the players about this fear and most of them simply operate under the code of, I can't think about it. It's too traumatic for me to think about what this might be doing to me in 10 or 20 years.

11:14:56

REHMDr. Cantu, you're quick to point out that one concussion does not necessarily lead to CTE?

11:15:08

CANTUNo, not at all, Diane. And in fact, I kind of like to say if you've seen one concussion, you've seen one concussion. All concussions are unique. They, some of them are severe, those that are severe have greater implications than those that aren't. And by severe, I mean, duration of symptoms last many months, sometimes even years.

11:15:28

CANTUThat's a totally different injury than somebody who just has symptoms for a few hours or day. so I don't think we can think about concussions just by the number and certainly our experience is when we're thinking about CTE we need to think about total brain trauma, it's not just at the concussion level. We have cases in the brain bank that did not have any recognized concussions.

11:15:54

CANTUSo it's total brain trauma, all those, over the course of an NFL player's career would be tens of thousands of sub-concussive blows count. I do want to slightly disagree in the sense of the players not being concerned about this. I agree with everything that's been said, most of them try to block it out and some do a very good job of that.

11:16:16

CANTUBut if we think back to the most recent collective bargaining agreement, which was hammered out between the NFL and the Player's Association, the Player's Association argued long and hard to reduce the number of full contact practices and they'd done it so well that they can actually have less than one week.

11:16:36

CANTUIt's 14 full contact practices over the 18 weeks of the season and that was done primarily with the recognition that they did not want to subject themselves to the head trauma that was taking place in those practices.

11:16:50

REHMDr. Robert Cantu, he's co-director of the Center for the Study of Traumatic Encephalopathy and author of "Concussion and Our Kids." Turning to you, Dr. Gioia, what do you think parents should make of this study?

11:17:13

GIOIAWell, you know I think, first of all, the issue of concussion and its, you know, greater awareness in our society and in all sports not just football, obviously, You know, should have parents sitting up and being alert and being, you know, appropriately educated and good consumers of their kids' sports. It's really important that a parent not go into, you know, bringing their kid into sport without any knowledge of how that sport is being coached, how it's being officiated, who is actually aware of recognizing these injuries, what they do about it, what are the policies.

11:17:52

GIOIASo parents have to become good consumers of this. they also themselves need to be educated about the injury itself because we know that injuries occur that escape the coach on the field and they need to know that if their son or daughter comes home from an activity, sporting activity, they can recognize that something may not be right and find the proper medical personnel. So I think that the key really for parents is to be good consumers but also be educated themselves.

11:18:22

REHMAnd when we come back after a short break, we'll talk with Mark Meana. He's chair of the Fairfax County Youth Football League in northern Virginia. One of the other sports I find myself wondering about is soccer when the hit is used to bounce that ball. Short break here, stay with us.

11:20:06

REHMAnd in this hour of our ongoing series Mind and Body we're talking about head injuries and the frequency of their leading to concussions which can eventually lead to serious brain damage. Mark Meana, you're chair of the Fairfax County Youth Football League in northern Virginia. You work directly with parents and kids. How concerned are parents and young people about playing football these days?

11:20:45

MEANAWell, certainly the parents have a very big concern. It's what you see in the newspapers. It's what you hear on the radio and what you certainly see on the TV. Again it's probably the lack of knowledge all the way around is what we're finding more and more, certainly in my career in operating a youth football league. Lately more and more people are hungry for information. Certainly the doctors, Dr. Cantu, Dr. Gioia, the information put out supported by the medical experts around the world is really, I think, the key to one of the solutions in player safety, in youth football especially.

11:21:27

MEANANot only the signs and symptoms, equipment fitting, coaches education, all of this goes in, which is a greater concern than I saw ten years ago, fifteen years ago.

11:21:39

REHMAll right. Dr. Cantu, I gather you're calling for the elimination of tackle football for kids under the age of 14. Tell me why.

11:21:54

CANTUWell, the main reasons that we believe tackle football should be eliminated for kids under the age of 14 is that the youth brain is more vulnerable to injury than is the adult brain. The youth brain does not have a full coating of myelin on the nerve fibers, that's the protection. It's kind of like coating on the telephone wire. It helps transmission, but it also gives strength.

11:22:16

CANTUYouth brains are also more susceptible to the excitotoxic shock injury, the metabolic injury of concussion. Youth brains are housed in disproportionately large heads. Kids by the age of four have received about 90 percent of the head circumference growth that they will have as an adult. And yet those very large heads are on very weak necks and that bobble-head-doll effect puts them at greater risk. And our youth are usually with the oldest equipment, usually with the least experienced coaches, usually with no medical personnel on the sideline.

11:22:57

CANTUAnd they've not really received informed consent in most instances in terms of the possible damage they're doing to their brains. That coupled with what I see across my desk every week that we see patients. And coupled with our experiences with the center for the study of traumatic encephalopathy where we're seeing early CTE in teenage kids that took the trauma that produced it in early years in life. It's just led me to believe that we don't want to see tackle football played the way it's currently played.

11:23:31

CANTUI certainly want football to be played. I want all sports to be played. We have recommendations for other sports as well, how they can be played more safely. We want to see more people playing them. And I think more people would at the youth level play football if it were flag football and the tackle was deferred.

11:23:52

REHMAll right. Dr. Gioia, I gather you disagree with calling for the elimination of tackle football for kids under 14.

11:24:05

GIOIAYou know, I disagree with its elimination, but I certainly fully agree that we need to continue to improve the game and its safety.

11:24:15

REHMHow?

11:24:15

GIOIAAnd I'll get to that in a minute. I just want to say that as we're better understanding what we can do more effectively, you know, one of the key things is going to be understanding what are those key ages that we really should be introducing this. And when should we not? And so we really need to be looking at that.

11:24:36

GIOIAI think, you know, one of the things that's been called for is certainly the reduction of forces that kids take. In other words, can we modify practices and the number of times that kids are exposed to contact while still teaching more effective techniques? I go back to my own personal history of both playing football and playing rugby. And thinking that you would never do in rugby what you do in football with a helmet.

11:25:07

GIOIAAnd getting away, I think, maybe over the decades from when I played, which was about 40 years ago, you know, in these games from learning how to tackle in different ways. We know that tackling is really one of the major parts of the game where the injury is sustained. But again I think that we need to understand what are the ages -- and as Dr. Cantu was saying, you know, those necks are weaker -- is there a certain age at which it is more effective to control the head and teach these kinds of techniques?

11:25:42

GIOIAYou know, we certainly see now some of the objections of, even at the professional level, being penalized for certain kinds of things. And quite honestly, these are folks that have learned, you know, frankly to use the wrong technique for 20, 30 years. And it's hard for them to change. I really think that we need to be starting early to be teaching the proper technique.

11:26:04

REHMStefan Fatsis, is it possible to make football safer for kids?

11:26:11

FATSISI don't think so given its current configuration. And I think part of the problem is simply who children are. You can teach all the technique you want, but children don't have the cognitive or physical ability very often, as five minutes on the sideline of any sports game, youth sports event will show you, to implement and control their bodies when they want to or when they should.

11:26:33

FATSISSo I'm very skeptical that it can change and I think coaches, for all their well meaning-ness, youth coaches are mostly parents. They are not particularly well educated, with all due respect to Mark. There is a lack of sophistication and there are conflicting motives when parents are coaching. They don't understand children very often and they don't understand the sport at a very nuance level. I think there are ways to ease children into tackle football when they go through puberty, as Dr. Cantu has indicated, without sapping their love or their interest in this sport.

11:27:08

FATSISPlaying flag football would be one way. Gradually padding them up and playing flag football while teaching different techniques would be another way. But I think to subject children to repeated sub-concussive blows from the ages of five, which is where Pop Warner football can begin, five years old and 35 pounds I think is -- just common sense is telling us this is no longer smart.

11:27:34

REHMAnd joining us now by phone from Richmond, Va. Mary Ann Easterling. Mary Ann's husband Ray Easterling played safety in the NFL for the Atlanta Falcons from 1972 to 1979. Good morning, Mary Ann.

11:27:57

MS. MARY ANN EASTERLINGGood morning, Diane.

11:27:59

REHMI know your husband Ray retired in '79. When did he begin to decline? What were his symptoms?

11:28:10

EASTERLINGAbout 1989, I noticed that he was having trouble sleeping, staying asleep and falling asleep. And he developed depression.

11:28:24

REHMAnd what else?

11:28:27

EASTERLINGAt the time, those were the kind of symptoms. And progressively he would make impulsive decisions, would not think through important things in our lives. He would say things that didn't make sense in the context of the conversation, couldn't get along with figures of authority very well.

11:29:01

REHMYou said at one point he would show up dressed inappropriately. What do you mean?

11:29:10

EASTERLINGWell, we would have family gatherings for Thanksgiving or Christmas and he would come in very late, 30 minutes, an hour late, still dressed in his running clothes.

11:29:23

REHMAnd what did you think was going on? Did you know then about CTE?

11:29:31

EASTERLINGOh no, I had no idea. I really had no clue what was going on.

11:29:37

REHMSo did you think it had any connection whatsoever to his playing football?

11:29:46

EASTERLINGI did not.

11:29:48

REHMAnd so you, I gather, began talking to other players' wives.

11:29:55

EASTERLINGNo. Actually what happened was I was online in December of 2010 and that's how late and how long the NFL buried the information, although they purport to want the best for the players and for their health. I found a connection to the Boston study that gave case studies of former players who had died either of suicide or accidental death. The description of their symptoms, particularly their cognitive behavior, were eerily similar to what I had been experiencing for 20 years with Ray.

11:30:47

REHMAnd sadly, I'm so sorry to note that your husband Ray committed suicide last April. What were his behaviors like just before he took his own life?

11:31:07

EASTERLINGHe was argumentative, difficult to follow any kind of information given him. He would forget where his keys were, his glasses, his wallet. But just before he died, he was beginning to be unable to drive in the daylight and know where he was.

11:31:38

REHMAnd then following his death, he was diagnosed with CTE?

11:31:48

EASTERLINGWell, prior to his death, about a year and two months, we had gone to a neuropsychiatrist here in Richmond, an excellent gentleman, Gregory O'Shanick, who diagnosed dementia due to concussions he sustained while playing football. But the CTE can't be -- at the -- well, even now it cannot be diagnosed until an autopsy is done on the brain. And that was conducted at University of Virginia by a neuropathologist there. And she did verify that there was CTE in his brain.

11:32:30

REHMSo I gather you are now involved in a lawsuit against the NFL.

11:32:37

EASTERLINGYes, ma'am.

11:32:38

REHMWhat do you hope comes from it?

11:32:42

EASTERLINGMy hope is that the NFL will recognize this body of people that are suffering and could potentially suffer due to the negligence of not revealing information that they have perpetuated. Recently they've -- Commissioner Goodell has turned that around somewhat. But prior to 2009 there was just -- there was nothing. And we have lots of players and families who are suffering due to the symptoms that I've described. And they need to be diagnosed, they need to get on medicine.

11:33:32

EASTERLINGAll these things are difficult for a player that has no health insurance, which was true in our case. Diagnoses and tests are very expensive. So that's my hope that they will be able to provide that kind of funding for the players and the potential sufferers.

11:33:53

REHMMary Ann, how old was your husband when he took his own life?

11:33:59

EASTERLINGSixty-two.

11:34:00

REHMAnd for how many years, seven years, he played for the Atlanta Falcons.

11:34:08

EASTERLINGHe did. He sustained a lot of damage, though, I believe during the training camp of 1980.

11:34:16

11:34:23

11:34:26

REHMAnd you're listening to "The Diane Rehm Show." Stefan Fatsis, up to now we've been talking about children. Mary Ann Easterling's husband, an adult, playing for the NFL. What is going on?

11:34:46

FATSISJust a growing, I think, awareness of -- as the doctors have talked about, of the risks of playing this sport. And I think the connection that we need to make between youth football and adult football -- we don't want to go too far. Tens of thousands of people, hundreds of thousands of children play football and don't develop symptoms into adulthood. But the distinction that I think needs to be made is that on the sides for defending youth football will tell you, well there are dangers in soccer. Yes, there are from heading the ball. There are dangers in ice hockey. There are dangers in lacrosse.

11:35:16

FATSISThere are dangers in all sports but those sports the primary function of those sports is not to run into each other. In football it is part of the game. It is the central part of the game. Tackling and blocking and colliding are the central part of the game. And I think that's what sets this sport apart from others. There are risks in everything that we play. that's what competitive sports involved. But football is distinct and I don't want to get dragged into making a false comparison between the risks in other sports and the risks in football.

11:35:51

REHMMark, I know that the NFL Commissioner Roger Goodell came to answer questions from parents during your season. What did he say?

11:36:05

MEANAWell, what's important in his visit was he actually got a good hands-on look at the Heads Up football pilot program that we have in place in the three areas of the country. Talked to the coaches, talked to the players, saw it, witnessed it. And saw the organized approach to trying to make it a better and safer game. You got to start somewhere. And then probably the most popular piece of it is when he addressed the parents in the stands. Certainly that was right on the heels of closing the officiating agreement that he had. So a lot of us were thinking a lot of questions were going to come from that.

11:36:42

MEANABut every single question focused on safety, concussion awareness. I didn't know this, I didn't know that. Certainly Dr. Gioia was there to fill in some of the details there. But they were genuinely concerned. They know the game from a spectator point of view but they don't know what goes on on the field, knowing how a helmet and shoulder pads are supposed to fit. What are some of the signs and symptoms? They're with them 99 percent of the time. They're in a better position than anybody.

11:37:14

MEANASo the commissioner opened it up to everyone and fielded all the questions. But the sincerity was there. And one of the mothers raised her hands and said, well my son is playing youth, now he's going to high school. What about that? And we were fortunate we had the head coach there and they had a director of student activities for Fairfax County to say we're going through.

11:37:33

REHMMark Meana, chair of the Fairfax County Youth Football League in northern Virginia. Your calls when we come back.

11:40:03

REHMAnd welcome back. We're talking about head injuries from sports, leading to concussions, leading to even more serious problems. I'm going to open the phones now, 800-433-8850. First to Jacksonville, Fla. Good morning, Ann, you're on the air.

11:40:29

ANNGood morning, Diane. And I truly appreciate this topic. And I want to sort of do a little meta analysis, everything I've heard. Ultimately I've been a psychiatric family, pediatric, neurologic nurse practitioner and so I've kind of developed a practice where, because of my own head injuries as a child and my own psychological traumas as a child, I always was trauma informed. And what I see in the field of behavioral health now, consumers need to be informed right up front to tell providers about minor head traumas they might've blown off along the way and/or the psychological traumas.

11:41:12

ANNBased on the fact of not getting these screenings done, the psychiatry field has ignored the history of the brain and only looked at the history, the behaviors or the thoughts or the disorder. WE need to improve the treatment model, other than diagnosing children with ADHD, bipolar, all forms of other illnesses and treating them with medicines that actually increase the symptoms by decreasing their seizure thresholds. When brains have been injured, they're more sensitive. And the medications that are usually used actually provide greater side effect profiles to an individual who's had chronic, traumatic injuries of that brain that could be from child abuse, homelessness, being in prison. The rates of those individuals...

11:42:02

REHMOkay. And I don't want to get too far off the subject, but I appreciate your call. Dr. Gioia.

11:42:10

GIOIAWell, I think the issue here is that we need a lot more information...

11:42:14

REHMYeah.

11:42:14

GIOIA...we need a lot more research to understand really the, you know, the nature of this injury to the brain and to the developing brain. We need to understand if you take that trauma to the head, you know, what is that recovery period that is necessary? Are there some individuals that seem to rebound more quickly and others more slowly and others possibly with, again, some lasting effect. You know, I think we know that at least, you know, my Boston colleagues, Dr. Cantu, Dr. Stern, Dr. McKee, you know, believe that there are some other factors that seem to be together with those blows to the head creating the chronic, traumatic encephalopathy.

11:42:53

REHMSuch as?

11:42:55

GIOIAWell, possibly a genetic predisposition, you know, possibly other biologic factors that mix.

11:43:01

REHMBut isn't that sort of looking in another direction when a head has been hit repeatedly? I mean, don't you look primarily there?

11:43:16

GIOIAWell, you really look at both factors. So again I'm not suggesting one more than the other, but we need to understand what are the factors because that may help us to guide ultimately down the road this individual, you know, with one injury toward a different activity or different sport. The point is that we really need more research on this issue, again, in all sports, but certainly as it relates to head trauma more generally.

11:43:40

REHMAll right.

11:43:40

GIOIAWe actually have -- we're pretty under-funded in those areas, and that's an area we really need to increase our funding toward.

11:43:47

CANTUDiane, I couldn't agree more with Gerry that we do need more research in this area, more funding for the research. And fortunately both I think are coming and a very large amount of it's coming from the National Football League who recently gave a $30 million grant to the NIH Foundation and has committed $100 million over a ten year period to jointly fund studies in this area. In the book we cover all sports because concussions happen in all sports. And certainly soccer is right up there at the top of the list for girls. And we monitor them in soccer to swimming, and discuss ways of making different sports safer.

11:44:34

CANTUBut I think it's very important that when we talk about the sport of football, which we are today, and we talk about it in terms of youth, that we also reflect on the fact that catastrophic football injuries in this country account for 97 percent of the catastrophic injuries we monitor at the National Center for Catastrophic Sports Injury Research at Chapel Hill.

11:44:57

REHMI see. All right.

11:44:58

CANTUIt's a huge proportion.

11:45:00

REHMOkay. Let's take a caller in Greensboro, N.C. Good morning, Julie.

11:45:07

JULIEGood morning. Thanks for taking my call.

11:45:09

REHMSure.

11:45:09

JULIEI was hoping your guest could just speak to the fact that recently there's been news about a higher incidence of ALS among NFL players and those suffering concussions and head injuries at some point in their life. My mother died two years ago of ALS at age 61. And she suffered a concussion several -- well, many years earlier from a ski accident. I'm wondering if more research is being done. And as a mother of a young lacrosse player, I constantly worry about hear injuries and because I don't want to see the same thing for my kids.

11:45:47

REHMOf course. Dr. Cantu.

11:45:50

CANTUYes, Diane, there have been now two publications, both with Ann McKee as the lead author from the work at Boston University. We have found a subset of individuals with chronic traumatic encephalopathy that also have a motor neuron disease. And their brains look like CTE, classical tau depositions at the depths of the sulci and the various locations, medial temporal lobe where it's most profound with CTE. But if you look at their spinal cords, they have tau deposition in the anterior horn cells and another kind of protein, TDP43, as well that's seen with ALS. So it looks like there is a variant of chronic traumatic encephalopathy that manifests as a motor neuron disease. And tragically these people die of the ALS aspects of it.

11:46:41

REHMSo where does that leave you, Dr. Cantu? Are you saying that you believe that the risks of these concussions are worth what could develop later on in terms of not only children below the age of 14, but as you, Dr. Gioia, mentioned high school kids and they're the ones who are playing as hard as they can?

11:47:24

CANTUWell, I think what we -- the dots we've connected so far -- and there is so much yet to learn, but the dots we've connected so far is that the risk for CTE is related to total brain trauma, not just concussions. But those sub-concussive blows count as well. We don't know how many of those have to equal a concussion, but we know that you can wind up with CTE without any recognized concussions.

11:47:51

CANTUPersonally I think it's hugely important that we get out youngsters active in sports. I think sports are very vital. I think physical activity is very, very important and sports is just one part of it. But I think at some point given the proper, informed consent and proper technique, scaling way back the contact and practices, I think sports like football can continue to be played, as long as people understand the risks involved.

11:48:21

REHMAll right. Mark Meana, we have lots of questions about helmets. And from Facebook, Football promotes head to head contact through the advances in, quote, "protective helmets." There are fewer traumatic head injuries in a sport like rugby because there is no helmet so the head is not used as a weapon. How do we demote the use of the head as a weapon when these heavy helmets become weapons themselves?

11:49:05

MEANAWell, I think I take a little bit different position. Of conquering this through education, helmets are there to prevent skull fractures, have certainly...

11:49:13

REHMBut do they?

11:49:14

MEANAPardon me?

11:49:15

REHMDo they?

11:49:15

CANTUYeah.

11:49:16

REHMDo they prevent?

11:49:17

MEANAThey certainly I think statistically. I'll defer to the medical community on that, that the reductions have been tremendous. Technology has come a long way as well from leather to where we are now. But I think what's more important is the education of all the volunteers that coach, administer, the parents, how they fit, what to do when it appears contact has happened on the field.

11:49:43

REHMOkay. What do you do? What would you do as a coach if it appeared somebody had a concussion on the field?

11:49:53

MEANAWell, I don't believe anybody can determine if they have a concussion on the field. If they exhibit signs and symptoms...

11:49:58

REHMOkay.

11:49:59

MEANA...any of those...

11:49:59

REHMYeah.

11:50:00

MEANA...disorientation, can't remember a play.

11:50:01

REHMSo what do you do? What do you do?

11:50:03

MEANAPull them out and sit them out until...

11:50:05

REHMJust sit them out is...

11:50:07

MEANASit them out from the contest and defer them to the parent if they -- or a qualified medical professional if they are available. But more importantly to make sure that somebody with the education and expertise can follow-up on that incident. And, you know, USA Football's Heads Up program is targeting that, not just the players, not just the coaches, everyone involved from the ground up. It's a comprehensive effort of education. I go back to seatbelts. It took a long time to prevent -- to get people to wear seatbelts and in 25 years it's saved approximately 147,000 lives.

11:50:48

REHMStefan, is that enough?

11:50:51

FATSISNo, I don't think it is, and here's why. USA Football which is the governing body for youth football has been promoting this Heads Up program to try to retrain athletes how to tackle and how to hit. Again, I think it's very difficult to control those behaviors once you're on the field. The impulse and making split second decisions in football often override the training that you have received. Ask any NFL player. The instinct is to use your head. And very often using your head -- not using your head is impossible. There was a study that I read about from Stanford University just this week that also indicated that hitting with the chest, not directly with the head, can also lead to some sort of brain injury through whiplashing of the head.

11:51:37

FATSISSecond, getting coaches on board is a Herculean task. Every sport tries to do it. I sat on a panel discussion here in Washington a few weeks ago. The head of USA Football talked about training 100,000 coaches, coming up with a program where they would have to pass 15 tests, and then there would be a monitor on the sidelines at every game to make sure that coaches were coaching properly. Also heard from someone promoting the use of neurotransmitters inside helmets. These are $1,000 helmets that you can buy.

11:52:11

FATSISAnd I left thinking we're doing all of this to help preserve a sport. A journalist colleague, a friend of mine, said afterward we're burning down the village in order to save it. What do we have to do to try to make this sport palatable? And Mark can answer some of those things.

11:52:27

MEANAYeah, I respectfully disagree with his approach. The -- you have to start somewhere and we're taking small steps. And concentration on anything is going to make it get better, a better, safer game. And in the case of Heads Up Football program, we are starting. It's part of drills. Why are the drills there? Are they scaled back? You know, what is the design of the drill? What is it supposed to accomplish? Eliminating contacting drills from so far apart.

11:52:58

MEANAOrganizing verbiage so everybody, all the wonderful teachers of the game, and not only this game, but other game, are all talking on the same page. And when you start doing all of this and you get an education from an accredited program, you've really taken giant steps toward a comprehensive solution.

11:53:16

REHMAnd you're listening to "The Diane Rehm Show." Stefan Fatsis, there's a lawsuit by former player who's against the NFL. You heard the wife of one of the players involved earlier. Tell me about this suit.

11:53:34

FATSISWell, there are more than 3,000 former NFL players that are participants in what is now a consolidated lawsuit in Philadelphia, class action against the NFL.

11:53:43

REHMWhat's the charge?

11:53:44

FATSISThe charge is that the NFL knew and didn't inform, as Mary Ann Easterling described, players about the risks of head injuries. Up until very recently in the early 2000's, the NFL continued to say that there was no link between football and head injuries. So this case was going to determine whether -- what the NFL knew and when they knew it, and whether it is liable for what could be billions of dollars in damages, and vast changes in how the NFL and its teams insure themselves, the league and players.

11:54:16

REHMHow strong a case do you think the players and their spouses have?

11:54:21

FATSISI'm not a lawyer, but if you look at past cases, I think the comparisons have been made to asbestos and to tobacco. And, you know, while this is not going to be on that scale, we're going to see in discovery what kinds of documents the plaintiffs surface and what kind of a defense the NFL's able to mount.

11:54:39

REHMCould we be seeing a winding down of professional football?

11:54:47

FATSISI don't think so. I think football is culturally embedded in this country. And I think with good reason. It's a fantastic game. I love to watch it. I watch it very differently than I watched it ten years ago. Having been around NFL players, I'm much more aware of what they're suffering through. Not only in terms of the physicality of the sport, but the mental pressure that they are placed under being on an NFL team. But it's a beautiful game. I mean, it really is. It's fun to play and that's why so many parents want to play it.

11:55:15

FATSISThe question is what can we do to ensure its safety. And I'm not sure how possible that is at the younger levels, but I think that Mark's right, they have to do whatever they can do to try to make the game safer if that's possible. But on a larger scale, I think just being aware of what these guys are going through creates, as fans and observers of the game, I think a more -- a smarter and a more sensitive public. And I think fans could do that.

11:55:39

REHMIf you had a child up to high school age, would you allow or want that son to play football?

11:55:52

FATSISNo, I probably would not. Not probably, I would not. Knowing what I know and seeing what I've seen at the adult level and what athletes go through, and also being cognizant of sort of how youth football in some places, not everywhere, operates, I wouldn't do it. If they wanted to be a kicker though, you know, that'd be okay.

11:56:09

REHMDr. Gioia.

11:56:11

GIOIAYou know, again, I take a moderated approach here and I would say that, again, as a good consumer, I would be examining the team and the league and being sure that they're using the most up to date methods that we know, that they are, you know, have safety measures in place, they're recognizing and they're responding appropriately, then I would allow my son to play.

11:56:29

REHMAnd, Dr. Cantu, what about you very quickly, please?

11:56:33

CANTUWell, very quickly, Tom Brady, Senior did not let Tom, Junior play until he was in high school. And John Madden has endorsed no playing under the age -- that is tackle football, under the age of 14. And certainly I go there too.

11:56:46

REHMAll right. And Mark Meana.

11:56:48

MEANAI disagree with some of the points made here. I believe that you need to play. You need to get to used to it. We need to make it better and safer. You can find a lot of people that'll say yes or no. We don't want to get into that.

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